Scars and Complications

IKUE SHIMIZU, MD
 How do you  Meticulous technique

make the scar  Treat complications


look good? Scar revision if all else fails
Surgical Complications
DIAGRAMS COURTESY OF DR. VALENCIA THOMAS
Preventing complications

Set yourself up for success

Preventing complications

 Pre-op assessment: risk factors

 H&P: are there any conditions that could affect healing?
 Smoking…
 Ensure realistic expectations during the informed consent process
 Good intraoperative surgical technique
 Keep a sterile field as much as possible
 Minimize tissue handling
 Proper suturing technique
 Hemostasis
 Manage any unavoidable complications appropriately
Factors affecting wound healing

 Medical conditions: diabetes, acute heart failure, uncontrolled hypertension, chronic

debilitating illness, etc
 Postpone if you have to, warn patient if you can’t
 Drugs: systemic steroids, immunosuppressive meds, VEGF inhibitors, tyrosine kinase
inhibitors
 Hold of at least 4-6 weeks before procedure
 SMOKING (dose dependent) – nicotine patches, decrease consumption 2 weeks pre, 1
week post
 Location: shoulders, central chest, upper arms and upper back more prone to hypertrophic
scars, keloids, and spreading
Complications

Complication rate: ~1.5% • Incomplete removal

• Hematomas, graft necrosis, dehiscence… • Recurrence (treat again)
• Undesirable cosmetic result
• Pain • Nerve damage
• Scar • Numbness/paralysis
• Bleeding • Life-threatening emergencies (rare)
• Infection • Cardiac arrhythmias
• Anaphylaxis
Nerve injury

 If you are operating in a danger zone, it is very helpful to evaluate pre-op function in the
area and document it. Any deficits present beforehand must be made apparent to patient,
otherwise they will think you caused it
 That said, you may still transect nerves, or even have temporary motor deficits due to
anesthesia
 Sensory nerve deficit: usually resolves, but may have paresthesias during healing
 Digits, forehead, scalp most prone to deficits long term
 Motor nerve deficit: paralysis. Rare in skin surgery but you need to be very aware of
danger zones (covered in anatomy lecture)
 Can try to reconnect if a major nerve. Call ENT or plastics
Arrhythmias?!

 Concern with ICDs

 If bipolar forceps or true electrocautery are used, intraoperative monitoring, cardiology
consultation, and postoperative evaluation are unnecessary for most patients
 For conventional electrosurgery, should be safe if > 15cm away from device and in bursts
of < 5sec
Anaphylaxis?!

 True lidocaine anesthesia is rare, but can be type I (immediate) or IV (DTH)

 Usually no cross reaction between esters and amides for type IV, not studied for type I (anaphylaxis)
 Type I is more common with esters and PABA metabolites
 Don’t forget about allergies to preservatives (e.g. methylparaben, metabisulfite)
 Epinephrine “allergy” is just a reaction to epinephrine(palpitations, headache, tachycardia, tachypnea, or
tremor)
 High doses or inadvertent intravascular injection)
 Short half life, no need to worry
 Is patient pale, sweaty and lightheaded, and about to faint? Likely vasovagal, check for slow regular
pulse. Keep patient supine and reassure
 Contact allergy to both chlorhexidine and povidone iodine can happen
OK…now back to not as scary
Common complications

 Pain
 Appropriate pain control
 For most skin surgery, combination scheduled acetaminophen + ibuprofen most effective
 Scar
 Revisions (later)
 Bleeding (most common)
 Minimize undermining
 Meticulous hemostasis
 Evacuate hematomas if they are new/semi-solid or actively expanding
 Ulcers, Dehiscence, Necrosis
 Support secondary intention healing
Infections

 Culture of wound (may be unreliable/contaminated)

 Sterile technique (don’t let your hair drag in the wound)
 Consider swabbing the staff for more infections than expected
 Revision after (at least) 6 weeks
 Manage erythema
Interrelated surgical
complications The terrible tetrad of infection,
hematoma, dehiscence, and necrosis can
all happen at once (dehiscence and
necrosis usually secondary to hematoma
and/or infection)
Cook JL and Perone JB. A prospective
evaluation of the incidence of
complications associated with Mohs
micrographic surgery. Arch Dermatol
2003 Feb; 139:143-52.
 WE DISCUSSED THIS
Hemostasis ALREADY
(ELECTROSURGERY)
 PRE-OP

Infection control INTRAOP

POST-OP
Antiseptic technique (pre-op)

 Even Mohs can be done clean (rather than sterile), but sterile gloves are easier to operate
with
 Skin is NOT sterile and cannot be sterilized
 Wipe and use antiseptic
 Clip hairs, DON’T shave (microscopic nicks)
 Popular: chlorhexidine (GP, GN, residual action, but toxic to tympanic membrane and cornea)
and povidone iodine/iodophors (GP, GN, some fungal spores, but slower acting and doesn’t last
as long)
 Some institutions are starting to ban use of chlorhexidine on face (Baylor…)
Clean technique during surgery

 DO NOT BREAK THE STERILE FIELD

 No throwing instruments
 Prep a wide area, cover everything else
 Basically the entire body area that can’t be covered
 Glove in and out as needed
 Suture tails should not be lying around on non-prepped or draped areas
 Patient should not reach up (scratch their nose for them if you have to)
Agent Action Spectrum Adv Disadv
Antiseptics
Isopropyl Alcohol Denatures proteins G+, G-
Some activity against fungi, viruses,
Cheap, rapid onset of action Have to let it dry
No residual activity, Flammable
mycobacteria Defats skin
No activity vs spores
Hydrogen Peroxide Radicals cause DNA Active against anaerobes Cheap Loses activity with exposure to blood
damage Can also kill keratinocytes
Hexachlorophene Phenol; disrupts cell G+, some G- Excellent residual activity Neurotoxic in infants, teratogenic
(phisohex) membranes A little TB/virus Slow onset
No fungus
Benzalkonium Chloride Cationic surfactant G+, G- (no pseudomonas) Prone to contamination, contact derm
(Zephiran) No residual activity
Povidone-Iodine Oxidation and substitution G+, G-, MTb, viruses, fungi Good residual activity Stains clothing
by free iodine Some spores? Partially inactivated by organic debris
ACD (can cross-react)
Chlorhexidine gluconate Biguanide disrupts cell G+, G-, viruses Broad Spectrum Middle ear toxicity, keratitis
(hibiclens) membrane; precipitation of Variable vs fungi, molds, yeasts Low skin absoprtion
cell contents No/min activity MTb, spores Excellent residual activity
Triclosan Phenol. Disrupts cell G+, G-, some fungi Has residual activity Avoid contact with eyes
membrane
 Antiseptics

Chlorhexidine (Hibaclens) Causes an allergic contact dermatitis (safe for eyes)

Povodine-iodine Should not be used in pregnant women or

infants
(teratogenic and neurotoxic) plus poor GN coverage

Hexachlorophene (Phisohex) Keratitis and otitis

Hydrogen peroxide Potentially flammable with cautery

Isopropyl alcohol Deactivated by blood

 Topical Antibiotics

Agent Spectrum Comments

Gentamicin GN + resistance
Neomycin GN, (-) pseudomonas ACD
Polymyxin B GN, (+) pseudomonas From Bacillus polymyxin
Bacitracin GP ACD
From Bacillus subtilis
Mupirocin GP, (+) MRSA Some ACD
Silver sulfadiazine Broad ACD (sulfa)
Reports of neutropenia, kernicterus
Intraoperative factors that can increase
infection risk

 Surgery > 2 hours (MAJOR)

 Breach in sterile field
 Too much dead tissue (aggressive electrocautery, crushed tissue, ischemic tissue)
 Minimize trauma so that wounds heal more rapidly: no crush! Use toothed forceps!
 Lots of charring/necrotic tissue will impede healing. Don’t be afraid to use suture ligation for hemostasis!
 Tension: if excessive can lead to tissue necrosis and dehiscence
 Also more uncomfortable post-op
 Do NOT pull percutaneous sutures tight if possible. It will lead to train track scars. If the wound is gaping, fix your deeps.
 If defect cannot be completely closed due to excessive tension, partial closure is OK! It is the same result as pulling too tight followed by
dehiscence, and is more controllable
 Remember: if it looks tight, it is
 Foreign bodies
 Braided sutures?? (controversy)
Antibiotic prophylaxis

 Can be given pre-, intra, or post-op

 PREVENTING SURGICAL SITE INFECTION IS NOT THE SAME AS PREVENTING
ENDOCARDITIS OR JOINT INFECTION
 Preventing endocarditis: AHA recommendations
 In patients with total joint replacements or specific cardiac diseases, no antibiotic prophylaxis
is indicated if the surgical procedure, along with an uncomplicated repair, is in a non-infected
cutaneous site
 Preventing joint infection: AAOS, ADA recommendations
 Prophylactic antibiotics are no longer recommended with some possible exceptions, note that
this is with DENTAL PROCEDURES (no guidelines for skin)
Heart conditions that need pre-op antibiotics

 FOR DENTAL PROCEDURES!!! (not skin procedures…)

 Prosthetic heart valves
 History of infective endocarditis
 Cardiac transplant with cardiac valvular disease
 Cardiac valve repairs within 6 months with prosthetic material
 Unrepaired congenital heart defects
 Repaired congenital heart defects with residual defect at site of prosthetic material
Joints and pre-op antibiotics

 NOT ROUTINE anymore, even for dental procedures (!)

 No recommendations specific to non-infected site at high risk of surgical site infection,
but you can consider it
 Infected, or mucosal site: consider it…
Surgical site infection and antibiotics

 Risk is very low in skin surgery, < 1%

 First step in prevention is meticulous handwashing and aseptic technique
 Different body sites have different flora
 Skin surgery (outpatient) main pathogens: S. aureus, coag neg Staph, Streptococcus, P. acne
 MRSA…
 Technically the best way to do it is PRE-OP (up to 120min before), NOT post-op
 AHA says up to 2 hours post op is OK
 Real life often interferes…
 Data DOES NOT support the role of extended courses of prophylactic post-op abx
What’s an infection?
 Skin flora (possible source of infection)
Location
Glabrous skin
Oral or nasal mucosa
Intertriginous areas (axillae,
perineum, interdigital webs,
antecubital fossa)
Sebaceous glands and follicles
Normal skin flora
Aerobic cocci: S. aureus; S.
saprophyticus; S.
epidermis; Micrococcus spp.
S.aureus; streptococci, lactobacilli,
corynebacteria, anaerobes (bacteroides) Anaerobes(Peptostreptococcus)
Corynebacterium minutissimum; C.
lipophilicus; C. xerosis; C.
jeikeium; Brevibacterium
epidermis; Acinetobacter spp.;
S. aureus
Propionibacterium acnes;
P. granulosum; P. avidum;
Yeast Malassezia furfur (pityrosporum
ovale)
Pathogenic bacteria
S. aureus ; S. pyogenes ; S.
epidermis (infrequently)
S. viridans
S. aureus ; E. coli,
Enterococcus; Bacteroides;
Pseudomonas aeruginosa;
Corynebacterium ; Candida spp.;
Serratia spp.
S. aureus ; Streptococcus ; anaerobic
bacteria; pseudomonas; Gram-
negative species
Notes
S. aureus can be either a contaminant
of the skin or a true resident
S. aureus can be resident flora in
anterior nares in 20–40% of the
population
S. aureus can be resident flora in the
perineum in 20% of the population
and in the axillae and toe spaces in 5–
10%
Who’s at risk?

 Recent studies have refuted notion that certain sites (e.g. below knee) or repairs (e.g.
grafts) are at higher risk of SSI
 That said, prophylaxis needs to be considered on individual basis/patient factors including
colonization, smoking, comorbidities, proximal infection, risk of morbidity
 If the site is already infected, the patient should be on antibiotics (why are you operating?)
 Personally, have noted most consistently with long (> 2 hour) surgeries
Wound classification and infection risk
Class Attributes % that develop
infections
Clean Immaculate technique 1–4
Non-inflammatory
Clean-contaminated Small breaks in technique 5–15
Gastrointestinal, respiratory or
genitourinary tracts entered without
gross contamination
Contaminated Major breaks in technique 6–25
Gross contamination from
gastrointestinal, genitourinary or
respiratory tracts
Dirty and/or infected Wound with acute bacterial infection ± >25
pus
Other factors that you may have seen

 SMOKING SMOKING SMOKING (nicotine)

 Diabetes: seems plausible but no controlled studies
 Advanced age (increased medications, comorbidities): no studies
 Immunosuppression: don’t want to increase pt’s own antibiotic resistance, so be careful! No
controlled studies
 Drugs: stop steroids for a few days
 Low granulocytes: consider abx if < 1000/mm3
 HIV: no change in risk
 Skin breakdown: can lead to contamination – increased risk
 Wound size: maybe?? Not many studies
 Preventing infection: pre-op dosing 30-60 min
before
Surgical site/procedure Pathogen of concern Antibiotic

Prevent heart or joint infection, keratinized skin S. aureus, B-hemolytic strep Cephalexin or dicloxacillin 2g PO
(inc. wedge excisions of ear, nasal flaps, all grafts) Cefazolin or CTX 1g IM/IV
Prevent heart or joint infection, or at high risk for SSI, mucosa Strep viridans, GN bacteria Amoxicillin 2g PO
Cefazolin or CTX 1g IV/IM
Ampicillin 2g IV/IM
PCN allergic As above Clindamycin 600mg PO/IM/IV
Azithromycin or clarithromycin 500mg PO
Prevent SSI, non-groin or legs keratinized skin S. aureus, B-hemolytic strep Cephalexin or dicloxacillin 2g PO
CTX or cefazolin 1-2g IV

Prevent SSI, groin or legs S. aureus, B-hemolytic strep, GN Cephalexin 2g PO

bacteria TMP–SMX DS 1tab PO
Levofloxacin 500mg PO
Prevent SSI, mucosa (oral or nasal) Strep viridans, GN bacteria Amoxicillin 2g PO

PCN allergic Clindamycin, TMP-SMX, or levofloxacin as above

Azithromycin or clarithromycin 500mg PO
Clindamycin (+ gentamicin) 600mg (+ 2mg/kg) IV
Intraoperative antibiotics

 Mixed with lidocaine or injected directly into wound

 Usually clindamycin, some nafcillin
 Studies: did reduce rate of infection, but it was already so low…was it necessary?
Post-operative antibiotics

 No support for routine use of longer course of post-operative antibiotics

 People do it anyway
 Treating intra-operative contamination? Just need one dose, preferably pre-op
 Treating post-operative contamination? No clear end-point
 What if it’s a granulating site?
 If the lesion takes 3 weeks to heal or more, what is 1 week of antibiotics going to do?
 Really should be no need for antibiotics the entire time, for most situations
 Me: treat if infected (minority viewpoint)
Special skin situations

 The ear
 Pseudomonas and S. aureus are concerns
 Ciprofloxacin, but beware tendon rupture esp if on steroids

 Lower extremities/groin
 Anaerobes and pseudomonas are concerns
 Treat if infected (me)
 Post-operative prophylaxis (many many other surgeons)
Is this even SSI?

 CULTURE IT (though can be unreliable/contaminated)

 Wound infections usually become evident 4–8 days postoperatively, if earlier than
consider strep infection (personal experience) and cover for it
 May not be super red!
 Doxycycline (commonly prescribed) won’t cover strep!
 Clean wound (irrigated with sterile saline), remove sutures if purulent to allow drainage
 Let it heal by second intent if purulent, revise later
Also: providers should stay safe!

 Needlesticks suck
 Proper handling of sharps: no recapping, don’t change blade by hand
 Have a plan! (for us, report to employee health)
 Transmission risk:
 HIV: 0.3%
 HBV: 1-6% if HbeV neg, 20-30% if HbeV pos
 HCV: 1.8% (but no prophylaxis recommended/available)
Treating complications

Happily ever after surgery

Give instructions in anticipation

 A little anticipation goes a long way!

 WRITTEN INSTRUCTIONS
 Don’t go sky diving
 Don’t toss hay bales to your horses
 Don’t build a treehouse
 The better you plan, the better your patient does
 Activity, instructions for wound care, instructions for complications
 Important for someone to call every patient postoperatively to check on progress and
answer questions
I bled on the mirror!

 Post op bleeding occurs mostly in first 24 hours

 Soaked dressing: needs attention. Remove it!
 Up to 72 hours postoperatively
 Clots are still fragile and easily dislodged
 First: hold pressure x 15-20 minutes x 2 cycles without peeking
 Use the clock to time it! No guessing!
 If pressure doesn’t do it, need to expose the wound and explore
 Hematoma occurs when blood collects in deadspace of wound instead of seeping out
Hematoma

 Time line:
 Liquid (early development): within hours, active hemorrhage
 Gel: within 48hours, fairly quickly
 Organization: becomes progressively more adherent over several days, harder to treat
 Liquefaction: after 7-10 days; eventually resorbed
What to do

 Acute: pressure (small) or throbbing pain (large, expanding)

 Evacuate any early, expanding hematomas: can lead to pressure dehiscence/necrosis and act as nidus for infection
 Evacuate, irrigate, and close up. Drain placement if needed
 +/- empiric antibiotics
 Organizing: if untreated for several days
 Thick, adherent
 Evacuate if still expanding or large
 Small organized hematomas can be allowed to reabsorb
 In this case, do not re-close the wound
 Liquefied:
 5 to 10 cc may be evacuated with an 18 gauge needle on a syringe
 Larger clots may require direct access through narrowest possible opening
 Warm compresses 30-60sec several times daily and bromelin 500mg 3-4xd may speed resolution
Hematoma
Healing hematoma
Ecchymoses

 Don’t worry, it’ll resolve…just interstitial leakage…

Post operative infections

 Thought to start during procedure but post op contamination also happens

 Don’t let the dog lick it (true story)
 Remove any soaked dressings
 Clean hands
 No excess manipulation
 Start 4–8 days after surgery: increasing redness, pain, swelling, and pus/lympangitis (red
streaks), systemic sx as it progresses
Treat the infection

 Rest, heat, elevate

 Drain if necessary (remove sutures), pack if deep cavity (iodoform gauze)
 Antibiotics: most likely culprit (staph aureus) and get culture, adjust if necessary. Make
sure to have strep coverage as well.
 Cepahlosporin, TMP-SMX or clinda if suspect MRSA, doxycycline
 Ear, foot: consider flouroquinolone (but tendon rupture and aortic rupture)
 Occluded area e.g. groin: cover anaerobes with sulfa drug
 Systemic symptoms or rapid spread may need IV
Wound infection and FTSG necrosis
Infection
These are not infections
Mimickers of infection

 Contact dermatitis: itchy, limited

 Candidal or dermatophyte infections
 Inflammatory suture reactions
 Viral infection (HSV)
Infection

 Rubor- Redness
 Tumor- Swelling
 Calor- Heat
 Dolor- Pain
 Bad infection: crepitus, fever, shock, cellulitis,
signs of endocarditis…

 Is this an infection?
This wound is not infected.

 Note the consistent 1.5 cm of erythema

 Absence of swelling
 No discharge
 No pain

 Granulating wound with graft loss

Dehiscence

 Despite your best efforts of good technique, hemostasis, gentle handling, etc, it may happen (e.g.
patient worked out)
 Separation of layers of wound (epidermolysis is if only epidermal edges are separated)
 Generally occur as result of other complications
 Hematoma, infection, seroma, premature suture removal…
 Re-suture if within the first 24 hours and not infected or necrotic
 E.g. if they just fell off the bed or similar
 If they can’t promise not to work out, no point…
 Otherwise, healing via secondary intent and revise the scar if necessary
 Can pack with iodoform gauze every 3-5 days if large
It takes months! Never > 80%
Necrosis

 Compression of blood vessels result in tissue necrosis

 Wound tension, crush injury, infection, hematoma, smoking all can be causes
 Design flaps, grafts carefully
 Flap tips are vulnerable, delay grafts if needed
 Sometimes can prevent if you see it early: pallor stage or cyanosis  replace sutures, elevate,
gentle heat, hyperbaric O2
 Best treated with observance, moist dressings
 Very minimal cleaning and debridement until you’re sure whatever is going to necrose has necrosed (don’t
extend the wound prematurely)
 Extensive debridement not recommended (may injure deeper tissues)
 Treat any infection
Suture issues

 Appear within weeks to months of surgery

 6 weeks is common, range 1-4 months
 Suture reaction (inflammation): pustules/papules (granulomatous inflammation)
 Express any pustules, remove any sutures, gentle massage if deep reaction
 Extrusion/spitting: remove if you can access it, otherwise wait
 Usually no long term effects
 Consider using a different material with future repairs if the reaction was very
inflammatory (e.g. polyglactin 910)
Chronic Ulcers, Flap Necrosis, Dehiscence: Supportive Care

 Special Dressings
 Hydrocolloids
 Alginates
 Vacuum dressings
 Medicated dressings
 Monitoring and addressing co-morbid conditions
 Stasis
 Hypertension
 Diabetes
Scar Revision
Cutting = scarring

 Scar formation is inherent to surgery and healing

 Ideal scar: nearly imperceptible fine line that blends in with natural creases/folds
 Poor cosmetic results:
 Contour/shape: wide, raised, depressed
 Color: red, or pigmented
 Surrounding structures: pulls on free margins, does not blend into natural lines
 Scar revision will NOT completely erase a scar—goal is to improve appearance
Options for scar revision

 Patience
 IL steroids (triamcinolone 5-10mg/ml x 0.1ml)
 Resurfacing:
 Lasers
 Non-ablative: PDL for red scars
 Fractional resurfacing: ablative, non-ablative
 Ablative CO2, Er:YAG
 Dermabrasion
 Massage (start at 1 month post op)
 Silicone gel sheeting for at least 2 months
 Surgical revision
IL steroids

 Triamcinolone 5-10mg/ml x 0.1ml

 Can start at 1 month post op, continue monthly
 Inject into bulkiest area at level of deep dermis or subcutaneous fat
 Good for hypertrophic linear scars, bulky grafts and flaps
 Watch out for atrophy! Don’t be too aggressive…
 Much harder to fix atrophy
Scar resurfacing

 Dermabrasion or ablative laser

 Sandpaper, bovie scratch pad
 Carbon dioxide laser, PDL, etc
 Perform at 4-8 weeks post op, get normal-appearing epidermis across scar boundaries
Lasers

 Darker skin types (IV or higher) need lower energy densities, so may still get suboptimal
results
 Need to avoid postoperative dyspigmentation
 As usual, do not treat actively infected skin
 Need to have good sun protection before/after
Non-ablative lasers

 PDL (585nm) is good for red scars (targets oxyhemoglobin)

 Also helps by promoting collagen remodeling and scar softening
 Best for red hypertrophic scars or for telangiectasias around scars
 Some have started immediately at suture removal, to prevent hypertrophic scars
 Side effects: purpura 7-10 days, edema 1-2 days

 Nd:YAG non-ablative (1064nm) is also promising for keloids and hypertrophic scars
Fractional lasers

 Semi-ablative or ablative resur­facing

 Fractional is safer than full on ablative resurfacing, but need 2-5 treatment sessions
 Target is water
 Can use 1420 and 1540 nm Erb:YAG or fractional 10 600 nm CO 2 laser
 Still get redness, swelling (3 days for Erb, 1 week for CO2), hemorrhagic crusting (CO2)
 No controlled studies, but thought to be effective due to normalization fo
collagenosis/collagenolysis cycle
 Beware post-inflammatory pigment alteration
Dermabrasion

 Spot dermabrasion is good for subtle texture abnormalities

 Power for larger, manual for smaller
 Ideally at 6-12 weeks post op
 Can help blend flaps, scars
 Don’t go too deep into dermis! (papillary is best)
 Can also use ablative lasers to do the same thing
 Beware pigment alteration, low risk of worsening scar
Scrub!
Unsatisfactory scars: specifics

 Ridgy/bumpy scars
 Atrophic or dyspigmented scar
 Hypertrophic scar
 Train tracking
 Spread scars
 Pincushioning/trapdoor deformity
 Pulling on free margin
Ridgy or bumpy scars

 Silicone scar sheets

 Resurface if they can’t wait
 For the future: less tension on percutaneous sutures
Atrophic or dyspigmented scars

 Atrophic scars are more difficult to treat than hypertrophic

 Fractional Er:YAG, CO2 have been noted to be somewhat effective in studies: stimulate collagen
formation
 Can also use chemical peels, dermabrasion, fillers
 Hypopigmented scars have very limited treatment options
 Fractional Er:YAG has been noted to have some success, but do NOT expect dramatic
improvement
 Even softening the border between normal and hypopigmented scar may look much better
Scar hyperpigmentation

 Significant risk in skin of color

 Immediate sun protection in the postoperative period
 Consider topical steroids in the post-op period in skin of color
 If manifests, treat with bleaching agents after 6 weeks
 Also retinoids, sunscreen
Hypertrophic scars

 Topical steroids or ILK can decrease thickness and pruritus, but also cause telangiectasias,
atrophy, widening
 Smaller scars may respond to massage
 Silicone gel sheets can help (or just occlusion and hydration)
 Excision if too bulky
Train tracking and spread scars

 Train tracking
 Avoid excess tension on closure, can also use relaxing incisions
 Can try to resurface, mixed results in my experience
 Excise if they reaaaaally hate it

 Spread scars
 May be unavoidable, but can try to use longer lasting sutures
 Sequential excision of scar, giving skin time to stretch (but will get longer final scar)
Surgical revisions: scar excision

 Spread or depressed linear scar: fusiform elliptical excision

 As always, proper eversion etc
 For sebaceous skin, bevel/counter-bevel can be helpful
 Skin needs to be lax (i.e. it needs to be a mature scar)
 For larger scars, can perform serial scar excisions to minimize tension
 Running subcuticular sutures to avoid track marks
 A re-excised scar will always be longer than original scar
Scar excision

30 degrees!
Advanced option: break up the scar

 Main idea: irregular line is less visible than

straight line
 Good for when scar is not along RSTLs
 W-plasty
 Mirrored zigzagging lines
 Base of triangles ~5mm, tips of “W” parallel to
RSTLs
 Better for shorter scars because it looks a bit
more obvious with longer ones
 Geometric broken-line closure
 Basically an elaborate W-plasty
 Better for longer scars because more
unpredictable lines
 Mirrored random geometric designs
(semicircles, triangles, squares)
 Undermine properly!
Trapdoor effect

Avoid by matching flap thickness to defect (thin the flap or deepen the
defect), wide undermining, and squaring off the flap
Repairing a trapdoor deformity

 Mild: ILK, massage

 Severe: lift flap, reflect it back, thin flap and deepen base, undermine wound edges, and
inset flap
Free Margins: Don’t Pull

 Free margins = natural skin margins that can be pulled “freely” by scar/tension
vectors
 Eyelids, nose, ears, lips
 To avoid pulling on free margins, you want to orient the tension vectors parallel
to the free margins
 Careful approximation of the free margin with percutaneous or vertical mattress
sutures to prevent notching
 Consider suspension sutures to support any weight especially for lower eyelid
 Different but related: webbing
 Don’t suture a line between two hilltops
This tension vector will cause a pull on the free margin
This tension vector (in white) will not cause pull on the alar rim.
Actual free margin is approximated to avoid any notching/denting
Webbing and avoiding it
May cause
webbing

Direction to
prevent a web
Ectropions

 Most complicated (medically) because can result in eye problems

 A mild ectropion may resolve spontaneously
 To avoid:
 Orient scars perpendicular to margin, oversize grafts (double), and size flaps generously
 Periosteal tacking sutures, Frost sutures (tack lower eyelid to eyebrow for 3 weeks)
 Use V-Y for mild, FTSGs from upper eyelid for more severe
 Can also still tack lower eyelid to eyebrow for 3 weeks
Ectropion Repairs

 Need to displace the eyelid upwards

 Z-plasty
 V to Y advancement
 Resuspension of the lower eyelid
 Canthopexy and tarsorrhaphy
A z-plasty in this direction will result in an upwards displacement of the eyelid
A V to Y advancement will result in an upwards displacement of the eyelid
Canthopexy and Tarsorrhaphy
FTSG for ectropion
Z-plasty

 Alters direction of scar and breaks up line so

it’s less visible
 Lengthens scar, so can help with deformation
of free margins
 Key concepts: common limb/diagonal and
angle size
 Wider angle will result in more gain in tissue
length
More on the Z

 Two zigzagging triangular flaps transposed in shape of a Z

 Make an incision along or around scar and outlined arms of Z
 Wide undermining and loosening of scar
 Tips of triangles are transposed to change direction of common limb into transverse limb
 Use equilateral triangles
Z-plasty in action
Transposing “b” and “c” result in “B” and “C”
The angle (here, 60) moving away from eachother
Common limb/diagonal (the scar)

B B
c
b c
A D D D
A
c b
b
C C

Note the gain in scar length

Wait, what? (a different angle)

B
A
A
A’
B’

B
Wait, what? (a different angle)

B’
A’
Angles and lengths

 Tissue gain in direction of common limb is directly proportional to the width of the base
of the flaps

 30° Z-plasty  25% gain in tissue length

 45° Z-plasty  50% gain in tissue length
 60° Z-plasty  75% gain in tissue length (90° change in scar direction)

 If you’re confused, incise the scar then repair it

Multiple Z-plasty (tip: use pen to mark what needs to go where)

 In inelastic skin and/or large Zs, the tension in the transverse diagonal direction can be a
bit much  can do multiple Zs
Z in action
V-Y, Y-V repairs

 V-Y repair can be used to lengthen a contracted scar

 Particularly useful around free margins when you’ve got an ectropion or eclabion
 Make a V-shaped incision along length of contracted scar, undermine, then push the V away to
relieve tension and length scar
 Final scar is Y shaped
 Y-V can be used to shorten a scar
 Make a Y incision and convert it into a V
V to Y in action